Skin Integrity And Wound Care (Exam 3)

Front 1

Skin

Back 1

largest organ of body
1st line of defense
synthesizes Vit D, thermoreceptor, protects against microbial infections

Front 2

Dermal-Epithelial Junction

Back 2

Separates the Dermis and Epidermis

Front 3

Epidermis

Back 3

Top layer of skin
Prevents foreign objects from penetrating body

Front 4

Dermis

Back 4

Inner layer of skin
Gives structure and flexibility to skin
supplies nutrients, removes wastes
senses pain, touch, pressure, and temperature

Front 5

Pressure Ulcer

Back 5

pressure sore, decubitus sore, bed sore.

Front 6

Factors for Pressure Ulcer/Bed sores

Back 6

pressure intensity: How much weight/gravity is put on skin
Blanching
Pressure Duration
Tissue Tolerance

Front 7

Risk Factors for Pressure Ulcer Development

Back 7

Impaired sensory perception:clients dont know they need to move to shift pressure
Impaired Mobility: parapelegic,immobile,hemoplegic
Shear (shifting of skin)
Friction
Moisture
Alterations in LOC

Front 8

Stage 1 Pressure Ulcer Formation

Back 8

1: intact skin, NONBLANCHABLE, erythema
not painful

Front 9

stage 2 Pressure Ulcer Formation

Back 9

partial-thickness skin loss INVOLVES EPIDERMIS, DERMIS OR BOTH
blister,abrasion,shallow crater
blood filled, boggy, no blanching

Front 10

Stage 3 Bed Sores

Back 10

full thickness skin loss: involving damage or necrosis to SUBCUTANEOUS TISSUES
possible tunneling and pain

Front 11

Stage 4

Back 11

full thickness skin loss with tissue necrosis or damage to MUSCLE,BONE OR SUPPORTING STRUCTURES
possibly showing bone, and tunneling

Front 12

Wound Classification: acute and chronic

Back 12

acute: timely and orderly healing: wound edges are clean and intact: surgery and trauma
Chronic: fails to heal in an orderly and timely process: diabetes,elderly, cardiovascular compromise, chronic inflammation

Front 13

Phases of wound healing (4)

Back 13

1. Hemostasis phase
2. Inflammatory phase
3. Proliferative phase
4. Remodeling or proliferation phase

Front 14

Hemostasis phase

Back 14

control of bleeding, clots form, injured blood vessels constrict, platelets accumulate

Front 15

Inflammatory phase

Back 15

acute= 3-4 days, chronic= longer
bringing in WBC and healing cells
debris phagocytosed

Front 16

Phases of healing

Back 16

1. Hemostasis phase
2. Inflammatory phase
3. Proliferative phase
4. Remodeling or proliferation phase

HIPR: Hot Italians Practice Religion

Front 17

Tell-tale signs of inflammatory phase

Back 17

erythema, edema, pain, warmth

WEPE
Women Enjoy Perfect Evenings

Front 18

Proliferative phase:

develops? produces?

Back 18

4-21 days; collagen produced; development of tensile strength and scar tissue; granulation tissue formation; epithelialization (new skin); new blood vessels form

Front 19

Remodeling/ Maturation Phase:
what leaves the wound?
lasts for..?
what is deposited?

Back 19

3-4 weeks; fibroblasts leave wound, can last for over a year. new and remodeled collagen is deposited; tightens and reduces scar size; tensile strength increases (regains 80% strength)---> scar

Front 20

Types of Wound Healing

Back 20

Primary, Secondary and Tertiary

Front 21

Primary wound healing
what kind of wounds?
risk for infection?

Back 21

tissue surfaces closed
low infection risk
healing is quick with minimal scar formation
ex: smooth surgical wound, edges come together nicely, well-approximated edges

Front 22

Secondary wound healing
examples?

Back 22

extensive tissue loss
edges cant be closed
repair time longer
scarring greater
susceptibility to infection greater
ex: falling and breaking your knee open, pressure ulcers, burns, severe laceration
may have to pack a wound

Front 23

Tertiary wound healing
(Delayed Primary intention)

Back 23

intentionally left open to drain
edema,infection, or exudate resolves, then is closed
example: when infections are lanced

Front 24

Hemorrhage
greatest after?
internal and external signs

Back 24

greatest in first 48 hours after surgery. bleeding from wound bed or site.
internal: increase in amount/type of drainage
external: hard painful swelling around edges, bloody discharge

Front 25

infection
change in?
what may develop?

Back 25

change in wound color,pain or drainage, fever, elevated WBC
delays wound healing
draining may develop and streaking may occur

Front 26

dehiscence
most common in?
preventative measures?

Back 26

partial or total rupturing of a sutured wound. occurs before collagen production( 3-11 days after injury)
most common in abdominal surgery
occurs after "strain"
splint their stomach: hug pillow when sneezing/coughing
obese patients

Front 27

Evisceration
do not allow..?

Back 27

MEDICAL EMERGENCY
protrusion of the internal visceral through an incision.
requires surgical repair
do not allow anything by mouth
nurse should place wet,sterile dressings over it

Front 28

Fistula

Back 28

abnormal tube-like passageway that forms between two organs or from one organ to outside the body
result of poor tissue healing after surgery,abscess,infection,trauma,inflammatory process, or disease process

Front 29

Types of wound drainage

Back 29

serous,purulent,serosanguineous,sanguineous

Front 30

serous drainage

Back 30

mostly serum
watery, clear of cells
ex:fluid in a blister

Front 31

purulent

Back 31

thick,yellow,green,tan or brown

Front 32

serosanguineous

Back 32

pale,red,watery: mixture of clear and red fluid

Front 33

sanguineous
indicates?

Back 33

bright red; indicates active bleeding

Front 34

Norton Scale
cutoff?

Back 34

physical and mental condition,activity, mobility, and continence
18 is cutoff; below 18 is at risk for skin integrity impairment

Front 35

Braden Scale

Back 35

sensory perception, moisture, activity, mobility, nutrition and friction/shear
18 is cutoff for risk

Front 36

nursing process: assessment

Back 36

assess areas of bony prominences at risk for skin breakdown.
assess:
review of systems,skin diseases,previous bruising, general skin condition, skin lesions, usual healing of sores

Front 37

assessment data: inspection and palpation

Back 37

skin color distribution, skin turgor, presence of edema, characteristics of skin lesions,

Front 38

assessment data: untreated wounds

Back 38

location, extent of tissue damage, wound length,width, and depth. bleeding, foreign bodies, associated injuries

Front 39

assessment data: treated wounds

Back 39

appearance,size,drainage,presence of swelling, pain, status of drains/tubes

Front 40

treating pressure ulcers

Back 40

minimize direct pressure, schedule and record position changes (every 2 hours), never use alcohol and hydrogen peroxide, obtain culture and sensitivity if infectied, clean and dress the ulcer

Front 41

vitamin C and zinc help

Back 41

form collagen

Front 42

_____ ______ is a good cleanser

Back 42

normal saline

Front 43

Fowler's position

Back 43

30 degrees at head of bed

Front 44

color guide for wound care
Red
Yellow
Black

Back 44

Red: protect--granulation tissue
Yellow: cleanse-- exudate (pus)
Black: debride-- tissue must come off

Front 45

Gauze

Back 45

retains dressings on wounds, bandage hands and feet

Front 46

Elasticized

Back 46

provide pressure to an area
improve venous circulation in legs

Front 47

Binders

Back 47

supports large areas of body
triangular arm sling, straight abdominal binder

Front 48

Hydrocolloid dressing

Back 48

protects wound from surface contamination

Front 49

hydrogel dressing

Back 49

maintains a moist surface to support healing

Front 50

wound V.A.C. dressing

Back 50

uses negative pressure to support healing

Front 51

if it's wet, ___it
if its dry, ___ it

Back 51

dry;wet

Front 52

debridement

Back 52

sharp
mechanical: scrubbing
enzymatic
autolytic
biological-- use of maggots to remove dead tissue

Front 53

Penrose drains

Back 53

hollow rubber tube placed directly or near the incision
drains into absorbant dressings

Front 54

Hemovac drains

Back 54

placed near the incision or where drainage is expected; suction is maintained through compression of the spring like mechanism

Front 55

Jackson-Pratt

Back 55

place near incision or where drainage is expected; gentle suction is maintained by compression of the bulb

Front 56

heat and cold therapy

Back 56

heat: vasodilated
cold: initial therapy, reduces swelling

Front 57

Mr. Thomas
77 years old
sacral pressure ulcer measuring 3x3cm
moderate tan drainage
no odor
periwound area firm and intact
edges of wound are macerated
wounds 75% red, 25% yellow

Back 57

stage 3